Recurring concern
Unreliable clinical safety-alert systems
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Request correctionFirst reported 12 Oct 2013•Latest report 1 Apr 2026
What this concern includes
Includes failures of clinical records, prescribing systems or related clinical information processes to create, retain, update, display or otherwise reliably surface safety alerts concerning patients, medicines or treatment.
Not included
- Excludes failures to act on a clearly received alert where the alerting system itself operated as intended.
- Excludes non-clinical alert systems such as police, custody, safeguarding or transport systems unless the report directly concerns a clinical safety-alert system.
- Excludes generic record-keeping or communication deficiencies that are not specifically tied to the reliability of a clinical safety alert.
- Reports
- 53
- Individual concerns
- 56
- Date range
- 2013–2026
- Stated actions
- 66
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure of software systems to communicate allergy markers to prescribing clinicians
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Introduce a new electronic clinical note that includes patient allergies.
Stated by Great Western Hospitals NHS Foundation Trust -
Action
Explore the IT infrastructure interface between the electronic medication and patient record systems.
Stated by Great Western Hospitals NHS Foundation Trust -
Action
Migrate the Emergency Department onto the Trust-wide server to improve access to electronic medication records.
Stated by Great Western Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The electronic handover system cannot be tailored to place key information, such as allergies, at the top for individual organisations.
Stated by Great Western Hospitals NHS Foundation Trust
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Concerns raised1
Failure to flag suicidal thoughts and potential overdose risk in patient notes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Circulate the antidepressant prescribing policy to GPs and nurses or nurse practitioners.
Stated by Woodley Centre Surgery -
Action
Require the assessing or reviewing GP to add a major alert when concerned about a patient’s risk.
Stated by Woodley Centre Surgery
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Concerns raised1
Unavailability of a system red flag for unexpected significant radiological findings
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Re-issue the radiological findings guidance to relevant clinical staff who joined after 2016.
Stated by Barnsley Hospital NHS Foundation Trust -
Action
Maintain updated guidance for communicating critical or urgent unexpected significant radiological findings.
Stated by Barnsley Hospital NHS Foundation Trust -
Action
Use electronic reporting systems to flag serious incidental radiological findings to treating clinicians.
Stated by Barnsley Hospital NHS Foundation Trust
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Action
Work towards implementing the Royal College of Radiologists’ standards for radiological report communication and fail-safe alerts.
Stated by Barnsley Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing Guidance and ICE electronic reporting systems are considered sufficient to significantly reduce the risk of similar radiological communication failures and future deaths.
Stated by Barnsley Hospital NHS Foundation Trust
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Position
Limited NHS resources and technical lack of uniformity prevent an electronic results workflow from being made fool-proof.
Stated by Barnsley Hospital NHS Foundation Trust
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Concerns raised1
Lack of alerts to staff when required patient safety assessments are incomplete
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to preserve documented penicillin and aspirin allergy information on the inpatient prescription and administration record
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of alerts identifying patients on long-term steroids
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to highlight hospital records with vital drug-sensitivity information
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of software programs to provide interruptive alerts for important diagnosed conditions
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
NHS Wales and the Welsh Assembly Government are the appropriate bodies to respond to concerns about this Welsh patient’s care.
Stated by Department of Health and Social Care
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Position
Operational matters for general practice in Wales fall outside the Department of Health in England’s responsibility.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of computerised recall systems to identify chronic disease patients requiring review beyond current prescribing
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of the GP computer system to alert clinicians to complete clinically relevant parameters
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026